https://doi.org/10.1007/s00167-021-06658-w HIP
The influence of pain catastrophizing and central sensitization on the reported pain after hip arthroscopy
Niels H. Bech1,2 · Inger N. Sierevelt1,3 · Aleid de Rooij4 · Gino M. M. J. Kerkhoffs2,5,6 · Daniel Haverkamp1
Received: 30 March 2021 / Accepted: 1 July 2021 / Published online: 11 July 2021
© The Author(s) 2021
Abstract
Purpose This study was conducted to investigate whether the pain catastrophizing scale (PCS) and the central sensitization inventory (CSI) are predictive factors for the reported pain after hip arthroscopy.
Methods A total of 37 patients undergoing hip arthroscopy for femoroacetabular impingement syndrome and labral tears were prospectively enrolled. All patients completed the PCS and CSI before hip arthroscopy. Postoperative pain was measured with the numeric rating scale (NRS) weekly the first 12 weeks after surgery by electronic diary.
Results At baseline, univariate analyses showed that both the CSI and PCS were significantly associated with the NRS outcome (p < 0.01). During 12 weeks follow-up, a significant decrease on the NRS was observed (p < 0.01). Univariate analyses showed that both the CSI and PCS were significantly associated with the NRS during follow-up. Multivariate mixed model analysis showed that only the PCS remained significantly associated with the NRS outcome with a ß of 0.07 (95% CI 0.03–0.11, p < 0.01).
Conclusion Results indicate that both the PCS and CSI are associated with the reported postoperative pain after hip arthros- copy. The PCS and CSI may be useful in daily practice to identify patients that possibly benefit from pain catastrophizing reduction therapy (e.g. counseling) prior to surgery.
Level of evidence IV
Keywords Pain catastrophizing · Central sensitization · Hip arthroscopy · Pain
Introduction
Postoperative pain after hip arthroscopy is usually measured as numeric rating scale (NRS) and is commonly used as outcome after surgery [17]. Although measuring of postop- erative pain with the NRS is well validated there are several patient-related factors that might influence the reported post- operative NRS score. In current literature, several factors are described as being risk factors for negative outcome after surgery, for example: female gender, increasing age, dura- tion of symptoms before surgery, presence of pre-operative osteoarthritis and an increased BMI [3, 16, 28].
Other non-orthopedic factors, such as patient mental health and psychological state, might influence the reported postoperative pain as well [10, 12, 27]. One of those factors might be central sensitization (CS) in which an abnormal enhancement of the pain mechanism may be present involv- ing the central nervous system [20, 22]. Central sensitization is defined as an increased sensitivity of the central nerv- ous system [5]. Central nervous system hyper-excitability is
* Niels H. Bech niels.bech@gmail.com
1 Specialized Center of Orthopaedic Research and Education (SCORE), Department of Orthopedic Surgery, Xpert Orthopedic Surgery Clinic, Amsterdam, The Netherlands
2 Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
3 Centre for Orthopaedic Research, Spaarne Ziekenhuis, Hoofddorp, The Netherlands
4 Amsterdam Rehabilitation Reserach Centre, Reade, Amsterdam, The Netherlands
5 Academic Center for Evidence-Based Sports Medicine (ACES), Amsterdam, The Netherlands
6 Amsterdam Collaboration on Health and Safety in Sports (ACHSS) AMC/Vumc, IOC Research Center, Amsterdam, The Netherlands
associated with various symptoms for example pain. Basi- cally, it can be said that processing of nociceptive inputs can differ between individuals resulting in a different perception of pain [20, 22]. For example, CS is a reported risk factor for persistent pain, patient dissatisfaction and lower quality of life in patients undergoing total knee arthroplasty [15]. For measuring symptoms related to CS the central sensitization inventory (CSI) is used and a cut-off value of 40 out of 100 points is determined to identify patients with central sensi- tization syndrome (CSS) [19, 21, 22].
Another non-surgical factor that may be of influence on the reported postoperative pain is pain catastrophizing (PC).
If PC is present, the patient has a tendency to magnify the threat value of a pain stimulus and to feel helpless in the presence of pain, also controlling pain-related thoughts can be a problem [24, 29]. PC has shown to be related to higher levels of pain and suffering and worse outcome after mus- culoskeletal surgery [1, 8, 13, 23]. PC is usually measured and validated with the pain catastrophizing scale (PCS) [29].
If factors, such as PC and CS, play a role in postoperative pain there might be a reason for routine pre-operative meas- uring both scores. The aim of this study is to investigate the role of PC and CS on the reported pain after hip arthroscopy and the hypothesis is that both CS and PC are of influence on the reported pain after hip arthroscopy.
Materials and methods
All included patients were part of a trial for which the study protocol was approved by the medical ethical committee (NL55669.048.15). Inclusion criteria for our current study were a confirmed diagnosis of Femoroacetabular Impinge- ment Syndrome (FAIS), age between 18 and 65 years and a completed CSI and PCS. FAIS is considered abutment of the proximal femur to the acetabular rim [2]. Diagnosis of FAIS was made with plain radiographs and MRI by measuring the alpha angle, lateral center edge angle and measuring a pos- sible cross-over sign. Exclusion criteria were previous hip arthroscopy or hip surgery, indications for hip arthroscopy other than FAIS and/or a BMI > 35.
All patients were operated by a single orthopedic sur- geon (D.H) with good hip arthroscopy experience (> 1000 procedures performed and > 150 annually). Procedures were performed in either a general hospital or a private orthopedic clinic. A total of 37 patients completed both the PCS and CSI and were included in our current study. Baseline char- acteristics are shown in Table 1.
Outcome
Pain was measured using a Numeric Rating Scale (NRS pain) and all patients were asked to complete a Central
Sensitization Inventory (CSI) and a Pain Catastrophiz- ing Scale (PCS) before surgery. The NRS was measured pre-operatively at baseline and weekly after surgery until 12 weeks post-operatively (by electronic diary). The out- come ranges between 0 and 10 where 0 means no pain and 10 worst possible pain. The NRS is a validated tool for measuring pain [6].
The CSI is a validated tool that is used to identify patients who have symptoms that may be related to CS [19]. The questionnaire consists of 25 questions and a score between 0 and 100 (best to worst) can be reached. A score of more than 40 indicates the presence of central sensitization [20].
PC was measured with the pain catastrophizing scale (PCS). The questionnaire which measures three components of pain catastrophizing being rumination, (e.g. "I can´t stop thinking about how much it hurts"), magnification (e.g. "I´m afraid that something serious might happen") and helpless- ness (e.g. "There is nothing I can do to reduce the inten- sity of my pain") [29]. The PCS is a well-validated 13-item questionnaire and patients can answer on a 0-to-4 Likert scale (0 = “not at all” and 4 = “all the time”) [29]. The total score ranges between 0 and 52 and a total PCS score of 30 represents clinically relevant level of catastrophizing [29].
The higher the score, the more catastrophizing is present.
Statistical analysis
Baseline and clinical characteristics are described as means with standard deviations (SD) in case of continuous varia- bles and frequencies with accompanying proportions in case of categorical variables. The association of potential risk factors for pain (CSI, PCS, age, gender, BMI) at baseline and
Table 1 Baseline and clinical characteristics (n = 37)
NRS numeric rating scale, CSI central sensitization inventory, PCS pain catastrophizing scale, SD standard deviation
Demographics
Age (years), mean (SD) 35.4 (10.4)
BMI, mean (SD) 23.6 (2.8)
Gender, n (%)
Male 23 (62)
Female 14 (38)
Operation details
CAM, n (%) 15 (41)
Pincer, n (%) 20 (54)
Labral repair, n (%) 20 (54)
Psoas lengthening, n (%) 2 (5)
PROMs
NRSpain, mean (SD) 4,0 (2.5)
CSI, mean (SD) 30.5 (17.1)
PCS, mean (SD) 16.6 (11.3)
12 weeks, and during follow-up (weeks) was assessed using linear regression analysis and mixed model analysis for repeated measures, respectively. Initially, univariate analyses were performed to identify potential risk factors. Factors that were significantly associated with the outcome (adjusted sig- nificance level of 0.10), were entered in a multivariate model (significance level 0.05). Adjustments for baseline values of the NRS were performed where appropriate. Fixed effects estimates with their 95% confidence intervals are presented (95% CI). A p value < 0.05 was considered statistically sig- nificant. No power analysis was performed since there were no data from previous studies to power on.
Results
At baseline and 12-week follow-up, univariate analyses showed that gender and both the CSI and PCS were sig- nificantly associated with the NRS outcome (p ≤ 0.01).
Multivariate analysis, however, revealed only the PCS as significantly being associated with the NRS with ß-values of 0.09 (p = 0.01) and 0.07 (p = 0.01), respectively (Table 2).
During 12-week follow-up, univariate analysis showed that gender, CSI, PCS were significantly associated with
the NRS. Multivariate mixed model analysis showed that only the PCS remained significantly associated with the NRS outcome with a ß of 0.06 (95% CI 0.01–0.10, p = 0.01) (Table 2). Overall, decrease of the NRS at 12-week follow- up was 3.1 points (95% CI 2.4–3.8).
Twelve patients (32%) reported a CSI > 40 and three patients (8%) a PCS > 30 points.
Additional univariate analysis using a cut-off value of 40 for the CSI showed that during 12-week follow-up, patients with a CSI > 40 scored on average 1,47 (95% CI 0.53–2.4) points higher on the NRS than patients with CSI < 40 (p < 0.01) (Fig. 1). This analysis was not performed for the dichotomized PCS as there were only three patients having a PCS > 30.
Discussion
The most important finding of the present study is that the pain catastrophizing scale (PCS) was significantly associ- ated with pain outcome at baseline, at 12 weeks as well as during 12-week follow-up in patients who had undergone hip arthroscopy. The central sensitization inventory (CSI) was only significantly associated with pain outcome after
Table 2 Univariate and multivariate analyses of factors associated with the NRS pain at baseline, at 12 weeks and during follow-up (0–12 weeks)
NRS numeric rating scale, CSI central sensitization inventory, PCS pain catastrophizing scale, NRS-BL Numeric Rating Scale at baseline, n.s not significant
*r2 = 0.40
#r2 = 0.44 Univariate analysis
Baseline At 12 weeks 0–12 weeks
ß (95%CI) p value ß (95%CI) p value ß (95%CI) p value
Follow-up (weeks) −0.24 (−0.27 to −0.21) < 0.01
Age −0.13 (−0.09 to 0.07) n.s Age 0.02 (−0.02 to 0.06) n.s Age 0.01 (−0.04 to 0.05) n.s
Gender 2.28 (0.88 to 3.68) < 0.01 Gender −0.12 (−0.95 to 0.70) n.s Gender −0.80 (−1.64 to 0.03) 0.06
BMI 0.11 (−0.14 to 0.36) n.s BMI 0.01 (−0.13 to 0.14) n.s BMI −0.03 (−0.17 to 0.11) n.s
CSI 0.07 (0.03 to 0.12) < 0.01 CSI 0.04 (0.01 to 0.06) 0.01 CSI 0.04 (0.01 to 0.07) < 0.01 PCS 0.12 (0.06 to 0.18) < 0.01 PCS 0.08 (0.05 to 0.12) < 0.01 PCS 0.08 (0.05 to 0.12) < 0.01 NRS-BL 0.19 (0.04 to 0.34) 0.01 NRS-BL 0.32 (0.18 to 0.46) < 0.01 Multivariate analysis
Baseline* At 12 weeks# 0–12 weeks
ß (95%CI) p value ß (95%CI) p value ß (95%CI) p value
Follow-up (weeks) −0.25 (−0.28 to −0.22) < 0.01
Gender 0.72 (−0.71 to 2.15) n.s Gender −0.01 (−0.88 to 0.85) n.s
CSI 0.04 (−0.01 to 0.08) n.s CSI 0.01 (−0.19 to 0.04) n.s CSI 0.01 (−0.02 to 0.04) n.s
PCS 0.09 (0.02 to 0.16) 0.01 PCS 0.07 (0.02 to 0.11) 0.01 PCS 0.06 (0.01 to 0.10) 0.01
NRS-BL 0.09 (−0.12 to 0.29) n.s NRS-BL 0.14 (−0.07 to 0.36) n.s
univariate analyses, and showed that patients with possible central sensitization, based on the cut-off value of 40 points, reported overall 1.5 points higher on the NRS compared to patients with a CSI < 40.
These results imply that the PCS was more strongly asso- ciated with pain outcome than the CSI. It is however debat- able how much clinical significance the PCS has with only a ß of 0.06 meaning that for every point on the PCS patients reported 0.06 point higher on the NRS. The minimal clinical important change of the NRS is on average 1 point or 15%
decrease in reported NRS [26].
There are some factors that are known to have a negative effect on the outcome after hip arthroscopy. These factors include increasing age, female gender and/or higher BMI [16, 28]. In our current study, we did not find any association between these factors and the outcome but this could have been caused because of the small sample size. Since no sam- ple size calculation was performed for this study, the study could also be underpowered to detect the effect of the CSI.
With respect to the dichotomized CSI, the difference of 1.47 points on the NRS with patients with CSI < 40 could indicate a clinically relevant effect [26]. As the variation of the PCS was too small to categorize patients as pain catastrophizing (n = 3), this analysis could not be performed for the PCS.
There is not much literature regarding the CSI and its effect on pain after hip arthroscopy. There are some papers that suggest a correlation between central sensitization and lower outcomes (or chronic pain) after total knee replace- ment surgery [18, 30]. In the paper of Jun Koh et al. the authors state that patients with pre-operative central sensiti- zation show limited benefit of total knee arthroplasty com- pared to non-central sensitization patients [15].
A recent study by Dumont et al. shows that patients with FAIS and/or a diagnosis of depression or anxiety have higher levels on the pain catastrophizing scale [9]. In patients undergoing total knee arthroplasty, the level of pain catastro- phizing is associated with higher postoperative pain, lower
quality of life and lower patient reported outcomes after sur- gery [4, 14, 25]. Pain catastrophizing can be modified and is under influence of several factors, such as surgery, physical therapy, cognitive behavioral therapy and pharmacotherapy [11]. Surgical treatment itself can be a reason for a decrease in pain catastrophizing but it is important to realize that there is a group of patients that might benefit from pre-operative counseling, physiotherapy or even pharmacotherapy [11].
There is literature that shows a significant decrease in pain catastrophizing after a cognitive behavioral therapy program prior to orthopedic surgery [7]. These lower pre-operative pain catastrophizing scores resulted in lower postoperative pain and higher patient reported outcome scores after sur- gery [7].
Patient understanding and patient selection is important in the goal to achieve satisfying results after hip arthroscopy.
The PCS and CSI may be of use in the pre-operative setting for measuring possible pain catastrophizing and identify those patients with high levels of pain catastrophizing or central sensitization. Both the PCS and CSI questionnaires are easy to use in daily practice and can give the orthopedic surgeon extra tools for identifying those patients that may benefit from pain catastrophizing reduction therapy (e.g.
counseling) prior to surgery.
This study has some limitations: a small sample size, a small variation of the PCS and no results for the group of patients with a PCS > 30. The small sample size may have caused some instability in our results and a larger sample size would be necessary for correction of confounders to identify predictors for the NRS outcome.
Conclusion
Results of this study show that both the PCS and the CSI are associated with the NRS reported pain at baseline and 12 weeks and during follow-up after hip arthroscopy.
Fig. 1 Mean (95% CI) NRS scores during 12-week follow- up stratified for the CSI (cut-off value 40). NRS numeric rating scale, CSI central sensitization inventory. Error bars represent 95% confidence interval
0 1 2 3 4 5 6 7 8
0 1 2 3 4 5 6 7 8 9 10 11 12
NRS PAIN SCALE
WEEKS AFTER SURGERY
CSI<40 CSI>40
Unfortunately this study has a small sample size and future research is needed to detect if these results hold and whether treating central sensitization or pain catastrophizing might improve indications and outcome after surgery.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
Declarations
Conflict of interest The author(s) declared no potential conflicts of in- terest with respect to the research, authorship, and/or publication of this article.
Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the insti- tutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Open Access This article is licensed under a Creative Commons Attri- bution 4.0 International License, which permits use, sharing, adapta- tion, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.
References
1. Abbott AD, Tyni-Lenné R, Hedlund R (2011) Leg pain and psychological variables predict outcome 2–3 years after lumbar fusion surgery. Eur spine J 20:1626–1634
2. Albers CE, Wambeek N, Hanke MS, Schmaranzer F, Prosser GH, Yates PJ (2016) Imaging of femoroacetabular impingement-current concepts. J Hip Preserv Surg 3:245–261
3. Bech NH, Kodde IF, Dusseldorp F, Druyts PAMC, Jansen SPL, Haverkamp D (2016) Hip arthroscopy in obese, a successful com- bination? J Hip Preserv Surg 3:37–42
4. Birch S, Stilling M, Mechlenburg I, Hansen TB (2019) The associa- tion between pain catastrophizing, physical function and pain in a cohort of patients undergoing knee arthroplasty. BMC Musculo- skelet Disord 20:421
5. den Boer C, Dries L, Terluin B, van der Wouden JC, Blankenstein AH, van Wilgen CP, Lucassen P, van der Horst HE (2019) Central sensitization in chronic pain and medically unexplained symptom research: a systematic review of definitions, operationalizations and measurement instruments. J Psychosom Res 117:32–40
6. Breivik EK, Björnsson GA, Skovlund E (2000) A comparison of pain rating scales by sampling from clinical trial data. Clin J Pain 16:22–28
7. Cai L, Gao H, Xu H, Wang Y, Lyu P, Liu Y (2018) Does a pro- gram based on cognitive behavioral therapy affect kinesiophobia in patients following total knee arthroplasty? a randomized, controlled trial with a 6-month follow-up. J Arthroplasty 33:704–710
8. Coronado RA, George SZ, Devin CJ, Wegener ST, Archer KR (2015) Pain sensitivity and pain catastrophizing are associated with persistent pain and disability after lumbar spine surgery. Arch Phys Med Rehabil 96:1763–1770
9. Dumont GD, Land J, Battle NC, Glenn RL, Menge TJ, Thier ZT (2020) Factors associated with high pain catastrophizing in patients undergoing hip arthroscopy for femoroacetabular impingement syn- drome. J Hip Preserv Surg 7:483–486
10. Ernat JJ, Song DJ, Brugman SC, Shaha SH, Tokish JM, Lee GY (2015) Mental health medication use correlates with poor outcome after femoroacetabular impingement surgery in a military popula- tion. J Bone Joint Surg Am United States 97:1272–1277
11. Gibson E, Sabo MT (2018) Can pain catastrophizing be changed in surgical patients? A scoping review. Can J Surg 61:311–318 12. Hayashi K, Morishima T, Ikemoto T, Miyagawa H, Okamoto T,
Ushida T, Deie M (2019) Pain catastrophizing is independently associated with quality of life in patients with severe hip osteoar- thritis. Pain Med 20:2220–2227
13. Høvik LH, Winther SB, Foss OA, Gjeilo KH (2016) Preoperative pain catastrophizing and postoperative pain after total knee arthro- plasty: a prospective cohort study with one year follow-up. BMC Musculoskelet Disord 17:214
14. Khan RS, Ahmed K, Blakeway E, Skapinakis P, Nihoyannopoulos L, Macleod K, Sevdalis N, Ashrafian H, Platt M, Darzi A, Athana- siou T (2011) Catastrophizing: a predictive factor for postoperative pain. Am J Surg 201:122–131
15. Koh IJ, Kang BM, Kim MS, Choi KY, Sohn S, In Y (2020) How does preoperative central sensitization affect quality of life follow- ing total knee arthroplasty? J Arthroplasty 35:2044–2049 16. Kuroda Y, Saito M, Çınar EN, Norrish A, Khanduja V (2020)
Patient-related risk factors associated with less favourable outcomes following hip arthroscopy. Bone Joint J 102-B:822–831
17. Lund B, Mygind-Klavsen B, Grønbech Nielsen T, Maagaard N, Kraemer O, Hölmich P, Winge S, Lind M (2017) Danish hip arthroscopy registry (DHAR): the outcome of patients with femo- roacetabular impingement (FAI). J Hip Preserv Surg 4:170–177 18. Lundblad H, Kreicbergs A, Jansson KA (2008) Prediction of per-
sistent pain after total knee replacement for osteoarthritis. J Bone Joint Surg Br England 90:166–171
19. Mayer TG, Neblett R, Cohen H, Howard KJ, Choi YH, Williams MJ, Perez Y, Gatchel RJ (2012) The development and psycho- metric validation of the central sensitization inventory. Pain Pract 12:276–285
20. Neblett R (2018) The central sensitization inventory: a user’s man- ual. J Appl Biobehav Res 23:e12123
21. Neblett R, Cohen H, Choi Y, Hartzell MM, Williams M, Mayer TG, Gatchel RJ (2013) The central sensitization inventory (CSI): estab- lishing clinically significant values for identifying central sensitivity syndromes in an outpatient chronic pain sample. J Pain 14:438–445 22. Neblett R, Hartzell MM, Cohen H, Mayer TG, Williams M, Choi
Y, Gatchel RJ (2015) Ability of the central sensitization inventory to identify central sensitivity syndromes in an outpatient chronic pain sample. Clin J Pain United States 31:323–332
23. Papaioannou M, Skapinakis P, Damigos D, Mavreas V, Broumas G, Palgimesi A (2009) The role of catastrophizing in the prediction of postoperative pain. Pain Med England 10:1452–1459
24. Quartana PJ, Campbell CM, Edwards RR (2009) Pain catastrophiz- ing: a critical review. Expert Rev Neurother 9:745–758
25. Riddle DL, Jensen MP, Ang D, Slover J, Perera R, Dumenci L (2018) Do pain coping and pain beliefs associate with outcome measures before knee arthroplasty in patients who catastrophize about pain? A cross-sectional analysis from a randomized clinical trial. Clin Orthop Relat Res 476:778–786
26. Salaffi F, Stancati A, Silvestri CA, Ciapetti A, Grassi W (2004) Minimal clinically important changes in chronic musculoskeletal
pain intensity measured on a numerical rating scale. Eur J Pain England 8:283–291
27. Sieberg CB, Klajn J, Wong C, Bowen G, Simons LE, Millis MB (2017) Predictors and trajectories of chronic postoperative pain fol- lowing hip preservation surgery. J Hip Preserv Surg 4:45–53 28. Sogbein OA, Shah A, Kay J, Memon M, Simunovic N, Belzile
EL, Ayeni OR (2019) Predictors of outcomes after hip arthroscopic surgery for femoroacetabular impingement: a systematic review.
Orthop J Sport Med 7:2325967119848982
29. Sullivan MJL, Bishop SR, Pivik J (1995) The pain catastrophizing scale: development and validation. Psychol Assess 7:524–532
30. Wylde V, Palmer S, Learmonth ID, Dieppe P (2013) The associa- tion between pre-operative pain sensitisation and chronic pain after knee replacement: an exploratory study. Osteoarthr Cartil England 21:1253–1256
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